Provider Demographics
NPI:1104263979
Name:PARK, MARIA A (PA)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:A
Last Name:PARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVENUE
Mailing Address - Street 2:COLORECTAL SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-5783
Mailing Address - Fax:414-955-0087
Practice Address - Street 1:9200 W WISCONSIN AVENUE
Practice Address - Street 2:COLORECTAL SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-5783
Practice Address - Fax:414-955-0087
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3119-23363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104263979Medicaid